2.b.i: Ambulatory ICUs

Project Description: An Ambulatory ICU will create a multi-provider team for patients with complex medical, behavioral conditions and social complexities. An Ambulatory ICU will also include communitybased non-physician care, complex specialty care (e.g., housing, rehab, etc.), for stable patients in need of additional social services. Clinical interoperability within the Ambulatory ICU will allow for efficient identification of patients and connect those patients in need of complex services by allocating levels of service only as needed.

It is expected that the applicant will implement this project at one or more sites consistent with the NukaModel which is endorsed by the Institute for Healthcare Improvement. The relationship-based Nuka System of Care is comprised of organizational strategies and processes; medical, behavioral, dental and traditional practices; and supporting infrastructure that work together - in relationship - to support wellness. Applicants should refer to the Nuka Model in developing the response: http://www.cmcgc.com/media/handouts/29IH01/M22_NukaModel_Eby.pdf

Nov 13, 2017

Fall Update 2017

As of DY2Q4, the Diabetes project has completed 71% of project milestones.

At BLHC, AICU has been implemented at two primary care sites: Bronxcare at 3rd Avenue and Health and Wellness Center. A weekly, hour-long, multidisciplinary case conference is held at each of these sites, devoted to discussion and treatment planning for patients needing care enhancement. Approximately 5 cases are presented at each site per week, including new patients and follow-up from previous cases. Any staff member attending the meeting can bring up a case or contribute to the discussion. The Care Transitions program provides a weekly list of clinic patients who have been hospitalized or see in the ED, and HealthFirst provides a list of their members who have been identified as high utilizers. Both of these lists aid the clinical staff in case selection for AICU. The aim of the case conference is to ensure the patient receives needed services, including medical, specialty, behavioral health, social and support services.

Sep 30, 2016

Project Update for September 2016

The Team continues its focus on how Health Home/community services will serve the Ambulatory ICUs as well as the identification of patients for the AICU patient registry.

Discussions continued with clinical leadership from Bronx Lebanon Hospital Center’s ED/Comprehensive Psychiatric Emergency Program (CPEP) /Department of Psychiatry/DSRIP Care Transitions and Care Coordination Teams to refer High Utilizer patients to the Ambulatory Care Project team for evaluation/intervention (part of the MAX Series/NYSDOH learning collaborative).

Aug 31, 2016

Project Update for August 2016

The Project team is in the process of hiring staff to activate the new Ambulatory ICU “site” (at existing Outpatient Clinics located 2 blocks from the Fulton Division of Bronx Lebanon Hospital Center).

Continued discussions occurred with clinical leadership from BLHC Hospital and its Emergency Department to refer High Utilizer patients to the Ambulatory Care Project team for evaluation/intervention (part of the MAX Series/NYSDOH learning collaborative).

Jul 31, 2016

Project Update for July 2016

The Team is focusing on the development of protocols/policies outlining how Health Home/community services will serve the Ambulatory ICUs as well as the development of a process to identify patients for the AICU patient registry.